To assist us in serving you, please complete the following confidential form. The information provided is important to your dental health.

Patient Information

Marital Status:

Insurance Information

I certify that I, and/or my dependent(s), have insurance coverage with (above stated) and assigned directly to Bello-Burgos Smiles all insurance benefits. If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Bello-Burgos Smiles may use my health care information and may disclose such information in the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits of the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.


Emergency Contact

Dental History

Have you ever been under the care of a doctor during the past two years?:

Dental Information

Smoke or chew tobacco?:
Clench or grind teeth?:
Bite your lips or cheeks regularly?:
Hold foreign objects in your mouth?:
Mouth breath while awake/sleep?:
Have tired jaws especially in the morning?:

Have you ever had

Orthodontic treatment?:
Oral surgery?:
Periodontal treatment?:
Your teeth or bite adjusted?:
A bite or mouth guard?:
A serious injury to mouth/head?:

Have you ever Experienced

Clicking/popping of the jaw?:
Pain? (Jaw joint, ear, side of face):
Trouble opening/closing mouth?:
Trouble chewing?:
Headaches, neck aches, shoulder aches?:
Sore muscles (neck, shoulders)?:


Are you pregnant?:
Are you taking birth control pills?:

Medical History

Heart (Surgery, Disease)
Chest pain
Congenital heart disease
Heart murmur
High blood pressure
Mitral valve prolapse
Artificial heart valve
Heart pacemaker
Rheumatic fever
Cortisone medicine
Swollen ankles
Diet (Special/Restricted)
Artificial joints
Kidney trouble
Thyroid problems
Contact lenses
Hay fever
Latex sensitivity
Allergy or hives
Sinus trouble

Indicate which of the following you have had or have

HIV positive
Blood transfusion
Sickle cell disease
Bruise easily
Liver disease
Yellow jaundice
Neurological disorder
Epilepsy or seizures
Fainting/dizzy spells
Psychiatric care
Psychological care
Radiation therapy
Cold sores/fever blisters
Hepatitis A or B
Venereal disease

I certify and understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered these questions truthfully to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication. For this, I will not hold my dentist, or any other member of their staff responsible for any errors or omissions that I may have made in the completion of this form.

Consent for use and Disclosure of Health Information

Section A: Patient Giving Consent

Section B: To the patient: Please read the following statements carefully Purpose of Consent: By signing this form, you will consent our use and disclosure of your protected health information to carry out treat­ment, payment activities and healthcare operations.

Notice of Privacy Practice: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make for you protected health information, and of other important matters about your protected health information. A copy of our notice accompa­nies this consent. We encourage you to read it carefully and completely before signing this consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our policy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including and revision of our notice, at any time by contacting: (305) 477-5299.

Consent of Communication: I give full consent to the doctor and his staff to contact me via, phone call, text message, email, correspond­ence, or any other media to contact me, they are authorized to leave messages on voice mail or in person, appointment reminders, post­cards, letters, statements, or other methods, in reference to any items that assist the practice in carrying out treatment, payment activities and healthcare operations.

Signature: By signing this form, I have had full opportunity to read and consider the consents of this consent form and your Notice of Privacy Practices, I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

Consent for Treatment

  1. I hereby authorize the doctor or designated staff to make x-rays, study models, photographs and any other aids deemed appropriate by the doctor to make a thorough diagnosis of (the Patients) dental needs.
  2. Upon such diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed upon by me, and to employ such assistance as required to provide proper care.
  3. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications. I acknowledge that the success of my treatment depends upon complying in home care instructions, oral hygiene and other instructions. I understand that no guarantees or assurances have been given by anyone as to the result that may be obtained.
  4. I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results.

I have read and understood all of the above.

Release of Dental Benefits

It is our pleasure to accept patients who have denta.1 insurance. Our office will be happy to file your insurance forms at no charge as a cour­tesy. However, we do require your copayment deductible (usually 20%-50%) to be paid at the time of service. We cannot bill your insurance company unless you give us your insurance information. You hereby authorize insurance claim reimbursement of dental benefits be paid directly to Bello-Burgos Smiles. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract, if your insurance company has not paid your account in full within 60 days, the balance will be automatically due and payable by you.

Financial Policy

We treat every patient with equal care with or without insurance. Unfortunately, some insurance companies do not always cover certain established, routine and accepted procedures. We feel you deserve the best treatment possible and should not be influenced by the insur­ance company's policy. Since we don't have access to each plan's contract, it is difficult for us to know every limitation, deductible, or allow­ance for every procedure. It is important for you to know your policy's coverage. Our practice is committed to providing the best treatment for our patients and we charge what is customary and reasonable for our area. You are responsible for providing the correct insurance in­formation and for all payments regardless of any insurance company's arbitrary determination for usual and customary rates.

I understand and agree that all services rendered me, my dependents, or others assigned by to me my account are charged directly to me. I further understand that I am personally responsible for payment. If I suspend or terminate care and treatment, any fees for services ren­dered will be immediately due and payable. For self-pay patients we expect you pay for the services rendered in FULL at the time of the visit. Should the fees for the professional services not to paid in accordance with the provisions herein, reasonable attorney's fee, plus ap­plicable finance charges and cost provided by law shall be included in the computation of the amount due. Finance charges can be applied to all amounts that are at least 30 days past due at the rate of 1.5% per month (18% annual rate). If the account is in default and turned over for collection, I acknowledge that I will be responsible for all reasonable costs associated with effecting collection.


  1. Co-Payments are to be paid in full the day of service, if not paid by the end of that business day, a service fee of $10.00 will be charged in addition to your co-payment.
  2. If there is no arrangement done of any form, any account balance outstanding longer than 28 days will be charged a $50.00 re-bill fee for each 28 day cycle.
  3. For returned or insufficient funds checks we will apply a fee of $50.00.
I have read the financial policy. I understand and agree to this financial policy.

Cancellation/Missed Appointment Policy

Your appointment has been booked, which makes it unavailable to other patients, therefore, we require at least 24 hours advance notice if you need to cancel or reschedule your appointment. For all missed or cancelled appointments with less than 24 hours no­tice, you will be charged $35.00 cancellation fee. Should you not receive a reminder of any form, it is still your responsibility to remember your appointment. Appointment reminders calls are a courtesy.
I have read and understand our cancellation/missed appointment policy:

Video, Audio, and Photographic Release

The undersigned hereby authorizes Doctors to use, reproduce and publish video, audio, photography or computer illustrations of your teeth. Mouth, for educational and media purposes and you waive claim against any party based on the usage of images or make any claim that the use of the images defames you or constitutes infringe­ment of your rights to privacy or any other right you may enjoy. It is not mandatory that you sign this paragraph and you agree that if you choose to do so, it is done so freely and voluntarily.